Irradiation WG Updates Presented by Debra Lane, MD on behalf of the Irradiation WG April 16th, 2015

Irradiation Guidelines NAC Draft Irradiation Guidelines have been resurrected due to: An interest in changing the CSA standard around irradiation parameters so that the standards reflect the European practice that is more appropriate for SAGM red cells. An official request from the PT CBS BLC for NAC to perform Irradiation recommendations was received November 3rd, 2014.

Irradiation Guidelines At the November F to F meeting (2014) it was decided that since the BC guidelines have been generated it would be prudent to compare the Draft National Advisory Committee’s Recommendations for use of Irradiated Blood Components against the BC Provincial Guidelines for agreement, gaps, etc.

Irradiation Guidelines Irradiation WG formed - first meeting held January 29th, 2015. Members: Doug Morrison - Irradiation WG Chair Dr. Dana Devine Dr. Debra Lane Dr. Brian Muirhead – NAC Chair Dr. Susan Nahirniak Dr. Lakshmi Rajappannair

Irradiation Guidelines WG agreed to extend the scope of NAC’s guidelines to include storage conditions of Red Blood Cells post irradiation: Concern raised is the fact that the guidelines in use in Canada are not aligned with the type of RBCs currently produced by CBS; saline-adenine-glucose-mannitol (SAGM) since converting to the Buffy Coat manufacturing process. Also noted the importance to include post storage recommendations since the Canadian Standards (CSA) group cannot get changes to take effect until the next iteration of the standard. It is also for the best interest of patient safety to change storage conditions noting that Irradiation guidelines may put more impetus on Health Canada to accept some of the recommendations of the CSA WG if sites are already following set recommendations.

Irradiation Guidelines A comparison table of the 2 guidelines was prepared by Veronica Woo – Project Coordinator @BC Provincial Blood Coordinating Office (PBCO). Members agreed that no further review required for those areas where both documents are in alignment . Indications that had slight and major differences were reviewed and discussed individually.  

Irradiation Guidelines The indications requiring further actions/discussions by members are: Acute Leukemia Non Hodgkin lymphoma (NHL), myeloma and chronic lymphoproliferative disorders Neonatal Exchange Transfusions (with no previous IUT ) Congenital heart defects in neonates and young infants One indication (Neonatal TOP UP Transfusion) requires data gathering for further investigation.

Neonatal Top Up Transfusions BC Guidelines All routine neonatal 'top-up' transfusions of neonates (< 4 months of age) with very low birth weights (VLBW) of <1,200 g should receive irradiated cellular components. Recognizing, that VLBW neonates comprise the vast majority of neonates who require transfusion, it is reasonable to establish a hospital specific policy to irradiate for all neonatal top-up transfusions, purely from a logistical perspective. NAC Draft Guidelines Presently no direction provided Requires data gathering; draft survey compiled for review.

Survey - Neonatal Top Up Transfusions In the absence of evidence a survey has been drafted to gather data Are irradiated cellular blood components provided for any of the following: Intrauterine transfusions Post partum top ups after an intrauterine transfusion Post partum exchange transfusions after an intrauterine transfusion Top up transfusions for all neonates (0-4 months) Top up transfusions for neonates less than 1200 grams Exchange transfusion in neonates

Neonatal Top Up Transfusions Are cellular blood components for neonates leukoreduced? 2a. If yes (Q #2) is it done at bedside or at the production stage (prestorage)? 3. Do you think that irradiation can be abandoned in the context of (universal) pre- storage leukoreduction for any of the clinical scenarios outline in question #1? 4. Do you think clinicians would accept a policy of not irradiating pre-storage leukoreduced cellular blood components for any of the clinical scenarios outlined in question #1?

Neonatal Top Up Transfusions Do you think additional studies are needed to improve strategies for preventing the usage of irradiation? 5b. If yes, (Q #5) please indicate your suggestions (systematic review, consensus conference, etc.). Is irradiation done on site at your hospital? 6b. If not,(Q #6) is there a manipulation to reduce the levels of K+?

Neonatal Top Up Transfusions 7. Has your institution been notified of a case of TAGvHD in a neonate? What is the annual number of neonates transfused with cellular blood components? (separate RBC and platelets) 9. What is the annual number of neonates transfusion events with cellular blood components? (separate RBC and platelets)

Irradiation Guidelines Next Steps: NAC Coordinator is to compile a list of Hospitals/Contact info for hospitals in Canada and the USA (with a level 3 or higher nursery). Once survey is finalized, NAC Coordinator to send survey to identified contacts and tabulate findings. Invite CCMNT members to collaborate with the NAC Irradiation WG?

Irradiation Guidelines